Veterans of the wars in Iraq and Afghanistan are more likely to receive opioids for pain if they have mental health disorders, researchers said.

Action Points

Note that PTSD is the most prevalent mental health disorder among veterans returning from Afghanistan and Iraq who use the VA health system.

Point out that this study found that a mental health diagnosis in these veterans, particularly posttraumatic stress disorder, was associated with an increased risk of receiving opioids for pain, high-risk opioid use, and adverse clinical outcomes compared with veterans without mental health disorders with pain diagnoses.

Veterans of the wars in Iraq and Afghanistan are more likely to receive opioids for pain if they have mental health disorders, particularly posttraumatic stress disorder (PTSD), researchers said.

Those with PTSD were nearly three times as likely to receive opioids for their pain as those without any mental health conditions (RR 2.58, 95% CI 2.49 to 2.67), Karen Seal, MD, MPH, of the VA Medical Center at the University of California San Francisco, and colleagues reported in the Journal of the American Medical Association.

"Returning combat veterans are presenting to primary care in large numbers and are seeking relief from physical and psychological pain," they wrote. "Extra care should be taken when prescribing opioids to relieve their distress."

PTSD is the most prevalent mental health disorder among veterans of the Iraq and Afghanistan wars who return home and use the VA healthcare system.

Little is known about the association between mental health disorders and patterns of opioid prescribing in veterans, so Seal and colleagues conducted a retrospective cohort study of 291,205 veterans who had entered the VA healthcare system between Oct. 1, 2005 and Dec. 31, 2010.

About half of them (141,029) had at least one non-cancer-related pain diagnosis. Of these, 15,676 were prescribed opioids for their pain.

Seal and colleagues found that a far greater percentage of those with PTSD and those with other mental health problems -- including depression, anxiety, alcohol use disorders, drug use disorders, and traumatic brain injury -- received opioids for their pain compared with those without mental health diagnoses (17.8% and 11.7% versus 6.5%).

That amounted to a nearly threefold increased risk of being put on opioids for pain among those with PTSD and almost a twofold increased risk for those with other mental health conditions (RR 1.74, 95% CI 1.67 to 1.82).

While all mental health diagnoses were associated with various forms of higher-risk opioid use, it was particularly pronounced among those with PTSD, the researchers said. Compared with those without mental disorders, vets with PTSD on opioids were more likely to:

Receive higher-dose opioids (RR 1.42, 95% CI 1.31 to 1.54)

Receive two or more opioids concurrently (RR 1.87, 95% CI 1.70 to 2.06)

Obtain early opioid refills, "indicating that they're using them more quickly than they should be," Seal said (RR 1.64, 95% CI 1.53 to 1.75)

With regard to concurrent sedative use, the researchers noted that PTSD patients are commonly prescribed benzodiazepines, even though there's a lack of evidence for their efficacy. At the same time, many studies have highlighted the risk of overdose from coprescription of benzodiazepines and opioids.

"Alternative therapies should be considered for patients with pain and PTSD," they wrote.

Taking opioids was associated with an increased risk of adverse clinical outcomes, including opioid-related accidents and overdoses, and alcohol and non-opioid-drug-related accidents and overdoses, for all veterans (RR 2.33, 95% CI 2.20 to 2.46), although it was most pronounced in those with PTSD, the researchers noted.

"Unfortunately, treatment with opioids among patients with mental health problems may result in or exacerbate substance abuse and worsening of mental health symptoms over time," they wrote.

They said their findings are in line with previous studies showing a link between higher opioid use in PTSD patients, especially those with the highest symptom severity scores.

They also noted that 77% of opioids were prescribed by VA primary care clinicians, showing it's possible that opioids may be prescribed "to treat a poorly differentiated state of mental and physical pain."

It's been suggested that patient distress "can drive potentially inappropriate opioid therapy, perhaps because physicians do not know how else to handle these challenging patients," they added.

The study may have been limited because VA databases are subject to clerical errors. Also, the authors stressed that for the main analyses, they selected a population of VA-enrolled returning veterans with pain diagnoses. As a result, their findings may not apply to all veterans of the Iraq and Afghanistan wars.

The authors still concluded that the findings "support further efforts to improve care of patients with comorbid pain and PTSD."

The study was supported by the Department of Veterans Affairs and the National Institutes of Health.

The researchers reported no conflicts of interest.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

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